Provider Demographics
NPI:1497238554
Name:WOOTAN, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:WOOTAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 E TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 RIVER ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4524
Practice Address - Country:US
Practice Address - Phone:530-257-5341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist